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Komatsu Y, Verweij EJTJ, Tiblad E, Lopriore E, Oepkes D, Agarwal P, Lam E, Leu JH, Ling LE, Nelson RM, Olusajo V, Saeed-Khawaja S, Tjoa ML, Zhou J, Amin U, Sirah W, Moise KJ. Design of a Phase 3, Global, Multicenter, Randomized, Placebo-Controlled, Double-Blind Study of Nipocalimab in Pregnancies at Risk for Severe Hemolytic Disease of the Fetus and Newborn. Am J Perinatol 2024. [PMID: 39197469 DOI: 10.1055/a-2404-8089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2024]
Abstract
OBJECTIVE Nipocalimab is a neonatal fragment crystallizable (Fc) receptor (FcRn)-blocking monoclonal antibody that inhibits placental immunoglobulin G (IgG) transfer and lowers circulating maternal IgG levels. In an open-label, single-arm, phase 2 study, nipocalimab demonstrated evidence of safety and efficacy that support further investigation in a pivotal phase 3 trial of recurrent hemolytic disease of the fetus and newborn (HDFN). The phase 3 AZALEA study aims to evaluate the efficacy and safety of nipocalimab in a larger population at risk for severe HDFN, defined as HDFN associated with poor fetal outcomes or neonatal death. STUDY DESIGN AZALEA is a multicenter, randomized, placebo-controlled, double-blind, phase 3 study enrolling alloimmunized pregnant individuals (N ≈ 120) at risk for severe HDFN based on obstetric history. Participants are randomized 2:1 to receive intravenous 45 mg/kg nipocalimab or placebo weekly from 13-16 to 35 weeks gestational age (GA). During the double-blind treatment period, participants receive standard-of-care weekly monitoring for fetal anemia until planned delivery at 37 to 38 weeks of GA. Postnatal follow-up periods are 24 weeks for maternal participants and 104 weeks for neonates/infants. RESULTS The primary endpoint is the proportion of pregnancies that do not result in intrauterine transfusion (IUT), hydrops fetalis, or fetal loss/neonatal death from all causes. Key secondary endpoints include the severity of HDFN as measured by a composite HDFN severity index, the earliest time to occurrence of IUT or hydrops fetalis, the modified neonatal mortality and morbidity index in liveborn neonates, and the number of IUTs received. Other endpoints are safety, patient- and caregiver-reported outcomes, pharmacokinetics, pharmacodynamics (e.g., IgG, FcRn receptor occupancy), and immunogenicity of nipocalimab. CONCLUSION AZALEA, the first placebo-controlled, randomized, multicenter, prospective trial in severe HDFN, is designed to evaluate the safety and efficacy of nipocalimab, a potential preventive and noninvasive intervention, in at-risk HDFN pregnancies. KEY POINTS · Severe HDFN leads to poor fetal/neonatal outcomes.. · IUTs are associated with complications and fetal loss.. · Nipocalimab blocks IgG recycling and placental transfer.. · Nipocalimab reduces fetal anemia and IUTs in early-onset severe HDFN.. · The phase 3 AZALEA study evaluates nipocalimab in severe HDFN..
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Affiliation(s)
- Yosuke Komatsu
- Janssen Pharmaceutical Companies of Johnson and Johnson, Cambridge, Massachusetts
| | - E J T Joanne Verweij
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Eleonor Tiblad
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick Oepkes
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Prasheen Agarwal
- Janssen Pharmaceutical Companies of Johnson and Johnson, Cambridge, Massachusetts
| | - Edwin Lam
- Janssen Pharmaceutical Companies of Johnson and Johnson, Cambridge, Massachusetts
| | - Jocelyn H Leu
- Janssen Pharmaceutical Companies of Johnson and Johnson, Cambridge, Massachusetts
| | - Leona E Ling
- Janssen Pharmaceutical Companies of Johnson and Johnson, Cambridge, Massachusetts
| | - Robert M Nelson
- Janssen Pharmaceutical Companies of Johnson and Johnson, Cambridge, Massachusetts
| | - Victor Olusajo
- Janssen Pharmaceutical Companies of Johnson and Johnson, Cambridge, Massachusetts
| | | | - May Lee Tjoa
- Janssen Pharmaceutical Companies of Johnson and Johnson, Cambridge, Massachusetts
| | - Jie Zhou
- Janssen Pharmaceutical Companies of Johnson and Johnson, Cambridge, Massachusetts
| | - Umair Amin
- Janssen Pharmaceutical Companies of Johnson and Johnson, Cambridge, Massachusetts
| | - Waheeda Sirah
- Janssen Pharmaceutical Companies of Johnson and Johnson, Cambridge, Massachusetts
| | - Kenneth J Moise
- Dell Medical School, The University of Texas at Austin, Austin, Texas
- Comprehensive Fetal Care Center at Dell Children's Medical Center, Austin, Texas
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2
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Moise KJ, Abels EA. Management of Red Cell Alloimmunization in Pregnancy. Obstet Gynecol 2024:00006250-990000000-01128. [PMID: 39146538 DOI: 10.1097/aog.0000000000005709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 07/18/2024] [Indexed: 08/17/2024]
Abstract
Rhesus immune globulin has resulted in a marked decrease in the prevalence of RhD alloimmunization in pregnancy; however, antibody formation to other red cell antigens continues to occur. Evaluation for the presence of anti-red cell antibodies should be routinely undertaken at the first prenatal visit. If anti-red cell antibodies are detected, consideration of a consultation or referral to a maternal-fetal medicine specialist with experience in the monitoring and treatment of these patients is warranted. Cell-free DNA can be used to determine fetal red cell antigen status to determine whether the pregnancy is at risk of complications from the red cell antibodies. First-time sensitized pregnancies are followed up with serial maternal titers, and, when indicated, serial Doppler assessment of the peak systolic velocity in the middle cerebral artery should be initiated by 16 weeks of gestation. When there is a history of an affected fetus or neonate, maternal titers are less predictive of fetal risk; if the fetus is antigen positive, serial peak systolic velocity in the middle cerebral artery measurements should be initiated by 15 weeks of gestation because intraperitoneal intrauterine blood transfusions can be used at this gestation if needed. The mainstay of fetal therapy involves intrauterine transfusion through ultrasound-directed puncture of the umbilical cord with the direct intravascular injection of red cells. A perinatal survival rate exceeding 95% can be expected at experienced centers. Neonatal phototherapy and "top-up" transfusions attributable to suppressed reticulocytosis often are still required for therapy after delivery.
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Affiliation(s)
- Kenneth J Moise
- Department of Women's Health, Dell Medical School, UT Health Austin, and the Comprehensive Fetal Center, Dell Children's Medical Center, Austin, Texas; and the Department of Obstetrics and Gynecology, Bridgeport Hospital/Yale University, Bridgeport, Connecticut
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Donepudi RV, Javinani A, Mostafaei S, Habich A, Miller J, Chmait RH, Shamshirsaz AA. Perinatal survival following intrauterine transfusion for red cell alloimmunized pregnancies: systematic review and meta-regression. Am J Obstet Gynecol 2024; 230:e1-e2. [PMID: 37839589 DOI: 10.1016/j.ajog.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/17/2023]
Affiliation(s)
- Roopali V Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 S Main St, Houston, TX 77030.
| | - Ali Javinani
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Shayan Mostafaei
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Annegret Habich
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden; University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Jena Miller
- The Johns Hopkins Center for Fetal Therapy, Johns Hopkins School of Medicine, Baltimore, MD
| | - Ramen H Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
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4
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Bardi F, Bakker M, Elvan-Taşpınar A, Kenkhuis MJA, Fridrichs J, Bakker MK, Birnie E, Bilardo CM. Organ-specific learning curves of sonographers performing first-trimester anatomical screening and impact of score-based evaluation on ultrasound image quality. PLoS One 2023; 18:e0279770. [PMID: 36730474 PMCID: PMC9894388 DOI: 10.1371/journal.pone.0279770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 12/13/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION First-trimester anatomical screening (FTAS) by ultrasound has been introduced in many countries as screening for aneuploidies, but also as early screening for fetal structural abnormalities. While a lot of emphasis has been put on the detection rates of FTAS, little is known about the performance of quality control programs and the sonographers' learning curve for FTAS. The aims of the study were to evaluate the performance of a score-based quality control system for the FTAS and to assess the learning curves of sonographers by evaluating the images of the anatomical planes that were part of the FTAS protocol. METHODS Between 2012-2015, pregnant women opting for the combined test in the North-Netherlands were also invited to participate in a prospective cohort study extending the ultrasound investigation to include a first-trimester ultrasound performed according to a protocol. All anatomical planes included in the protocol were documented by pictures stored for each examination in logbooks. The logbooks of six sonographers were independently assessed by two fetal medicine experts. For each sonographer, logbooks of examination 25-50-75 and 100 plus four additional randomly selected logbooks were scored for correct visualization of 12 organ-system planes. A plane specific score of at least 70% was considered sufficient. The intra-class correlation coefficient (ICC), was used to measure inter-assessor agreement for the cut-off scores. Organ-specific learning curves were defined by single-cumulative sum (CUSUM) analysis. RESULTS Sixty-four logbooks were assessed. Mean duration of the scan was 22 ± 6 minutes and mean gestational age was 12+6 weeks. In total 57% of the logbooks graded as sufficient. Most sufficient scores were obtained for the fetal skull (88%) and brain (70%), while the lowest scores were for the face (29%) and spine (38%). Five sonographers showed a learning curve for the skull and the stomach, four for the brain and limbs, three for the bladder and kidneys, two for the diaphragm and abdominal wall and one for the heart and spine and none for the face and neck. CONCLUSION Learning curves for FTAS differ per organ system and per sonographer. Although score-based evaluation can validly assess image quality, more dynamic approaches may better reflect clinical performance.
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Affiliation(s)
- Francesca Bardi
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- * E-mail: (FB); (CMB)
| | - Merel Bakker
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ayten Elvan-Taşpınar
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Monique J. A. Kenkhuis
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jeske Fridrichs
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marian K. Bakker
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Erwin Birnie
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Caterina M. Bilardo
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- * E-mail: (FB); (CMB)
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Practice patterns amongst fetal centers performing intrauterine transfusions (PACT): An international survey study. Eur J Obstet Gynecol Reprod Biol 2022; 274:171-174. [PMID: 35661539 DOI: 10.1016/j.ejogrb.2022.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 05/11/2022] [Accepted: 05/25/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Fetal anemia secondary to incompatibility between maternal-fetal blood types can result in hydrops and demise. Intrauterine transfusions have improved survival in experience centers. Our objective was to determine the practice patterns amongst fetal centers. STUDY DESIGN Thirteen fetal centers across the world were surveyed. Results from all participating centers were recorded, analyzed, and presented as ratios. Questions on the survey were related to experience of the physician, preferred methods of transfusion, fetal surveillance, and timing of delivery. RESULTS Differences amongst centers were as follows: 54% of the centers performed transfusions in operating room, the remaining did them in a clinic room or close to the operating room; 31% did not use maternal anesthesia, 31% used oral or intravenous sedation and 38% used a combination of local with oral or intravenous sedation. The similarities include: 84% performed intravenous transfusions, while 2 centers reported intraperitoneal and intracardiac transfusions were performed for very early cases; 85% of centers performed the last transfusion at 34-35 weeks and 77% electively delivered their patients at 37 weeks. CONCLUSION Method of transfusion and delivery timing was similar in most centers; however, differences were seen in location of procedure, anesthetic coverage, and surveillance. Further assessment is needed to determine if these differences in practice have any potential neonatal effects.
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Sánchez-Durán MÁ, Higueras MT, Avilés-García M, Maiz N, Rodríguez-Aliberas M, Arévalo S, Vázquez E, Ruiz Campillo CW, Carreras E. Perinatal outcomes and central nervous system abnormalities following intrauterine fetal transfusion: 17 years' experience in a tertiary center. Transfusion 2020; 60:2557-2564. [PMID: 32955746 DOI: 10.1111/trf.16087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/23/2020] [Accepted: 06/29/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND This study aimed to describe the perinatal outcome and central nervous system (CNS) anomalies in fetuses undergoing red blood cell (RBC) intrauterine transfusion (IUT). METHODS AND MATERIALS This was an observational single-cohort study carried out at Vall d'Hebron University Hospital in Barcelona, Spain, between 2002 and 2018 in women undergoing RBC IUT for suspected fetal anemia. Primary outcomes were adverse perinatal outcome (intrauterine or neonatal death and termination of pregnancy [TOP]), prenatal or postnatal CNS anomalies, and significant neurological impairment. RESULTS A total of 145 RBC transfusions were performed in 68 pregnancies of 60 women. The median gestational age for the first transfusion was 26 weeks (range, 18-32). Twenty-two (32%) fetuses were hydropic at the first transfusion. Fifty-eight pregnancies (85.3%) resulted in live births and 10 (14.7%) in adverse perinatal outcomes. Adverse perinatal outcomes were associated with hydrops (odds ratio [OR], 6.69; 95% confidence interval [CI], 1.53-29.23; P = .012) and gestational age at first transfusion (OR, 0.69; 95% CI, 0.54-0.89; P = .04). Four (5.9%) cases of cerebellar hemorrhage were diagnosed prenatally. In 14 (35%) of the 41 neonates undergoing brain ultrasound and/or magnetic resonance imaging (MRI) abnormalities were reported. The median follow-up was 6.5 years (range, 3 months to 19 years). Significant neurological impairment was reported in two cases (4.2%). CONCLUSION In fetuses undergoing intrauterine RBC transfusion, the survival rate is high, particularly in the absence of hydrops and if the gestational age at first transfusion is above 22 weeks. Significant neurological impairment is uncommon, despite the fact that postnatal CNS anomalies at ultrasound or MRI are frequent.
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Affiliation(s)
- María Ángeles Sánchez-Durán
- Obstetrics Department, Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - María Teresa Higueras
- Obstetrics Department, Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Mayte Avilés-García
- Obstetrics Department, Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Nerea Maiz
- Obstetrics Department, Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
| | | | - Silvia Arévalo
- Obstetrics Department, Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Elida Vázquez
- Universitat Autònoma de Barcelona, Bellaterra, Spain.,Paediatric Radiology Department, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - César W Ruiz Campillo
- Universitat Autònoma de Barcelona, Bellaterra, Spain.,Neonatology Department, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Elena Carreras
- Obstetrics Department, Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
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Construction of Maternal-Fetal Medicine Centers in the Netherlands. MATERNAL-FETAL MEDICINE 2020. [DOI: 10.1097/fm9.0000000000000060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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8
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Kang SL, Jaeggi E, Ryan G, Chaturvedi RR. An Overview of Contemporary Outcomes in Fetal Cardiac Intervention: A Case for High-Volume Superspecialization? Pediatr Cardiol 2020; 41:479-485. [PMID: 32198586 DOI: 10.1007/s00246-020-02294-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 01/17/2020] [Indexed: 01/04/2023]
Abstract
Fetal cardiac interventions (FCI) offer the opportunity to rescue a fetus at risk of intrauterine death, or more ambitiously to alter disease progression. Most of these fetuses require multiple additional postnatal procedures, and it is difficult to disentangle the effect of the fetal procedure from that of the postnatal management sequence. The true clinical impact of FCI may only be discernible in large-volume institutions that can commit to a standardized postnatal approach and have sufficient case volume to overcome their FCI learning curve.
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Affiliation(s)
- Sok-Leng Kang
- Division of Cardiology, Labatt Heart Centre, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Edgar Jaeggi
- Division of Cardiology, Labatt Heart Centre, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Mt Sinai Hospital, Toronto, ON, M5G 1X5, Canada
| | - Rajiv R Chaturvedi
- Division of Cardiology, Labatt Heart Centre, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada. .,Fetal Medicine Unit, Department of Obstetrics and Gynecology, Mt Sinai Hospital, Toronto, ON, M5G 1X5, Canada.
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Zwiers C, Oepkes D, Lopriore E, Klumper FJ, de Haas M, van Kamp IL. The near disappearance of fetal hydrops in relation to current state-of-the-art management of red cell alloimmunization. Prenat Diagn 2018; 38:943-950. [PMID: 30187936 PMCID: PMC6282502 DOI: 10.1002/pd.5355] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/24/2018] [Accepted: 08/29/2018] [Indexed: 11/16/2022]
Abstract
Objective In this study, we aim to evaluate trends in the condition of fetuses and neonates with hemolytic disease at the time of first intrauterine transfusion (IUT) and at birth, in relation to routine first‐trimester antibody screening, referral guidelines, and centralization of fetal therapy. Method We conducted a 30‐year cohort study including all women and fetuses treated with IUT for red cell alloimmunization at the Dutch national referral center for fetal therapy. Results Six hundred forty‐five fetuses received 1852 transfusions between 1 January 1987 and 31 December 2016. After the introduction of routine first‐trimester antibody screening, the hydrops rate declined from 39% to 15% (OR 0.284, 95% CI, 0.19‐0.42, P < 0.001). In the last time cohort, only one fetus presented with severe hydrops (OR 0.482, 95% CI, 0.38‐0.62, P < 0.001). Infants are born less often <32 weeks (OR 0.572, 95% CI, 0.39‐0.83, P = 0.004) and with higher neonatal hemoglobin (P < 0.001). Neonatal hemoglobin was positively independently associated with gestational age at birth, fetal hemoglobin, and additional intraperitoneal transfusion at last IUT. Conclusion Severe alloimmune hydrops, a formerly often lethal condition, has practically disappeared, most likely as a result of the introduction of routine early alloantibody screening, use of national guidelines, and pooling of expertise in national reference laboratories and a referral center for fetal therapy. What's already known about this topic?
Severe alloimmune hydrops is associated with impaired outcome on both the short term and the long term.
What does this study add?
With routine early alloantibody screening, national guidelines, and pooling of expertise in national reference laboratories and a referral center for fetal therapy, severe alloimmune hydrops has almost disappeared. Survival of hydrops cases no longer differs from hemolytic disease of the fetus and newborn cases without hydrops. Children treated with intrauterine transfusions are now in better condition at birth.
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Affiliation(s)
- Carolien Zwiers
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frans J Klumper
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Masja de Haas
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, The Netherlands.,Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands.,Immunohematology Diagnostic Services, Sanquin Blood Supply, Amsterdam, The Netherlands
| | - Inge L van Kamp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Zwiers C, Lindenburg ITM, Klumper FJ, de Haas M, Oepkes D, Van Kamp IL. Complications of intrauterine intravascular blood transfusion: lessons learned after 1678 procedures. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:180-186. [PMID: 27706858 PMCID: PMC5601196 DOI: 10.1002/uog.17319] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 08/19/2016] [Accepted: 09/22/2016] [Indexed: 05/14/2023]
Abstract
OBJECTIVE Maternal alloimmunization to fetal red-blood-cell antigens is a major cause of fetal anemia, which can lead to hydrops and perinatal death if untreated. The cornerstone of management during pregnancy is intrauterine intravascular blood transfusion (IUT). Although this procedure is considered relatively safe, complications continue to occur. The aim of this study was to evaluate rates of procedure-related complications and perinatal loss following IUT, and their change over time, in order to identify factors leading to improved outcome. METHODS This was a retrospective analysis of all IUTs for red-cell alloimmunization performed at the national referral center for fetal therapy in The Netherlands, from 1988 to 2015. Differences in complication rates and their associations with alterations in transfusion technique after 2001 were assessed. RESULTS Between 1988 and 2015, 1678 IUTs were performed in 589 fetuses. For IUTs performed in 2001 and onwards, there was significant improvement in survival (88.6% vs 97.0%, P < 0.001) and a decline in procedure-related complications per fetus (9.8% vs 3.3%, P = 0.001) and per procedure (3.4% vs 1.2%, P = 0.003) compared with those performed before 2001. Procedure-related perinatal loss declined from 4.7% to 1.8% per fetus (P = 0.053). Beneficial changes in transfusion technique were routine use of fetal paralysis, increased use of intrahepatic transfusion and avoidance of arterial puncture. CONCLUSIONS IUT has become an increasingly safe procedure in recent years when performed by experienced hands. The chosen technique should be fine-tuned according to the patient's individual situation. The declining complication rates are most likely related to center volume: this rare procedure is best performed in experienced fetal therapy centers. © 2016 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C. Zwiers
- Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - I. T. M. Lindenburg
- Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - F. J. Klumper
- Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - M. de Haas
- Department of Red Blood Cell Serology, Sanquin DiagnosticsAmsterdamThe Netherlands
- Department of Immunohematology and Blood TransfusionLeiden University Medical CenterLeidenThe Netherlands
| | - D. Oepkes
- Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - I. L. Van Kamp
- Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
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Moon-Grady AJ, Baschat A, Cass D, Choolani M, Copel JA, Crombleholme TM, Deprest J, Emery SP, Evans MI, Luks FI, Norton ME, Ryan G, Tsao K, Welch R, Harrison M. Fetal Treatment 2017: The Evolution of Fetal Therapy Centers - A Joint Opinion from the International Fetal Medicine and Surgical Society (IFMSS) and the North American Fetal Therapy Network (NAFTNet). Fetal Diagn Ther 2017; 42:241-248. [PMID: 28531885 PMCID: PMC5739586 DOI: 10.1159/000475929] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 04/18/2017] [Indexed: 01/23/2023]
Abstract
More than 3 decades ago, a small group of physicians and other practitioners active in what they called "fetal treatment" authored an opinion piece outlining the current status and future challenges anticipated in the field. Many advances in maternal, neonatal, and perinatal care and diagnostic and therapeutic modalities have been made in the intervening years, yet a thoughtful reassessment of the basic tenets put forth in 1982 has not been published. The present effort will aim to provide a framework for contemporary redefinition of the field of fetal treatment, with a brief discussion of the necessary minimum expertise and systems base for the provision of different types of interventions for both the mother and fetus. Our goal will be to present an opinion that encourages the advancement of thoughtful practice, ensuring that current and future patients have realistic access to centers with a range of fetal therapies with appropriate expertise, experience, and subspecialty and institutional support while remaining focused on excellence in care, collaborative scientific discovery, and maternal autonomy and safety.
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Affiliation(s)
- Anita J Moon-Grady
- The Fetal Treatment Center, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
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Zwiers C, van Kamp I, Oepkes D, Lopriore E. Intrauterine transfusion and non-invasive treatment options for hemolytic disease of the fetus and newborn – review on current management and outcome. Expert Rev Hematol 2017; 10:337-344. [DOI: 10.1080/17474086.2017.1305265] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Carolien Zwiers
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Inge van Kamp
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Enrico Lopriore
- Divison of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
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Balancing Patient Access to Fetoscopic Laser Photocoagulation for Twin-to-Twin Transfusion Syndrome With Maintaining Procedural Competence: Are Collaborative Services Part of the Solution? Twin Res Hum Genet 2016; 19:276-84. [PMID: 27087260 DOI: 10.1017/thg.2016.24] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The benefits of fetoscopic laser photocoagulation (FLP) for treatment of twin-to-twin transfusion syndrome (TTTS) have been recognized for over a decade, yet access to FLP remains limited in many settings. This means at a population level, the potential benefits of FLP for TTTS are far from being fully realized. In part, this is because there are many centers where the case volume is relatively low. This creates an inevitable tension; on one hand, wanting FLP to be readily accessible to all women who may need it, yet on the other, needing to ensure that a high degree of procedural competence is maintained. Some of the solutions to these apparently competing priorities may be found in novel training solutions to achieve, and maintain, procedural proficiency, and with the increased utilization of 'competence based' assessment and credentialing frameworks. We suggest an under-utilized approach is the development of collaborative surgical services, where pooling of personnel and resources can improve timely access to surgery, improve standardized assessment and management of TTTS, minimize the impact of the surgical learning curve, and facilitate audit, education, and research. When deciding which centers should offer laser for TTTS and how we decide, we propose some solutions from a collaborative model.
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Hui L, Tabor A, Walker SP, Kilby MD. How to safeguard competency and training in invasive prenatal diagnosis: 'the elephant in the room'. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:8-13. [PMID: 26643796 DOI: 10.1002/uog.15806] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 10/21/2015] [Accepted: 10/27/2015] [Indexed: 06/05/2023]
Affiliation(s)
- L Hui
- Perinatal Medicine, Mercy Hospital for Women, Heidelberg, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
- Public Health Genetics, Murdoch Childrens Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - A Tabor
- Center of Fetal Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Faculty of Medicine and Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - S P Walker
- Perinatal Medicine, Mercy Hospital for Women, Heidelberg, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - M D Kilby
- Fetal Medicine Centre, Birmingham Women's Foundation Trust, and University of Birmingham, Birmingham, UK
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Deka D, Dadhwal V, Sharma AK, Shende U, Agarwal S, Agarwal R, Vanamail P. Perinatal survival and procedure-related complications after intrauterine transfusion for red cell alloimmunization. Arch Gynecol Obstet 2015; 293:967-73. [PMID: 26493554 DOI: 10.1007/s00404-015-3915-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 10/12/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To study the perinatal survival and procedure-related (PR)complications after intrauterine transfusions in red cell alloimmunization. METHODS Prospective data of 102 women with Rh-alloimmunized pregnancy undergoing intrauterine intravascular transfusion for fetal anemia, from January 2011 to October 2014 were analyzed. Main outcome measures were perinatal survival and procedure-related (PR) complications. RESULTS A total of 303 intrauterine transfusions were performed in 102 women. Of 102 fetuses, 22 were hydropic at first transfusion. The mean period of gestation and hematocrit at first transfusion was 26.9 ± 3.3 weeks (range 19.7-33.8 weeks) and 17 ± 7.82 % (range 5.7-30 %), respectively. Average number of transfusions was 2.97 (range 1-7) per patient. Overall survival was 93 % and mean period of gestation at delivery was 34.5 ± 1.94 (range 28.3-37.4) weeks. Mean hematocrit at delivery was 36.9 ± 8.77 % (range 10-66 %). Fetal death occurred in four cases (3PR), neonatal death occurred in three cases (2PR). Emergency cesarean delivery after transfusion was performed in four pregnancies. The total PR complication rate was 2.97 %, resulting in overall PR loss in 1.65 % per procedure. CONCLUSION Our results compare favorably with other studies published in the literature. Intravascular transfusion is a safe procedure improving perinatal survival in fetuses with anemia due to Rh-alloimmunization.
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Affiliation(s)
- Dipika Deka
- Department of Obstetrics and Gynecology and Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Vatsla Dadhwal
- Department of Obstetrics and Gynecology and Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
| | - Aparna K Sharma
- Department of Obstetrics and Gynecology and Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Unnati Shende
- Department of Obstetrics and Gynecology and Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Sumita Agarwal
- Department of Obstetrics and Gynecology and Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Ramesh Agarwal
- Department of Obstetrics and Gynecology and Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Perumal Vanamail
- Department of Obstetrics and Gynecology and Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
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Curvas de aprendizaje de sumatoria acumulada (CUSUM) en procedimientos básicos de anestesia. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1016/j.rca.2014.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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17
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Aguirre Ospina OD, Ríos Medina ÁM, Calderón Marulanda M, Gómez Buitrago LM. Cumulative Sum learning curves (CUSUM) in basic anaesthesia procedures. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1016/j.rcae.2014.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Lindenburg ITM, van Kamp IL, Oepkes D. Intrauterine blood transfusion: current indications and associated risks. Fetal Diagn Ther 2014; 36:263-71. [PMID: 24903741 DOI: 10.1159/000362812] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 04/09/2014] [Indexed: 11/19/2022]
Abstract
Fetal anemia is a serious complication in pregnancy and associated with perinatal mortality and morbidity. During 25 years of worldwide experience with intravascular intrauterine blood transfusion, a variety of indications have been described. Intrauterine transfusion (IUT) treatment is considered most successful for fetal anemia due to red cell alloimmunization. Moreover, the use of this procedure has also been reported in pregnancies with parvovirus B19 infection, fetomaternal hemorrhage and placental chorioangiomas, for example. This review focuses on the current indications of intrauterine blood transfusions. In addition, we describe the potential complications of IUT treatment.
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Affiliation(s)
- Irene T M Lindenburg
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Peeters SHP, Van Zwet EW, Oepkes D, Lopriore E, Klumper FJ, Middeldorp JM. Learning curve for fetoscopic laser surgery using cumulative sum analysis. Acta Obstet Gynecol Scand 2014; 93:705-11. [PMID: 24773155 DOI: 10.1111/aogs.12402] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 04/17/2014] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To identify a learning curve and monitor operator performance for fetoscopic laser surgery for twin-to-twin transfusion syndrome using cumulative sum analysis. DESIGN Retrospective cohort study. SETTING National tertiary referral center for invasive fetal therapy. POPULATION A total of 340 consecutive monochorionic pregnancies with twin-to-twin transfusion syndrome treated with fetoscopic laser coagulation between August 2000 and December 2010. METHODS A learning curve was generated using learning curve cumulative sum analysis and cumulative sum methodology to assess changes in double survival across the case sequence. Laser surgery was initially performed by two operators, joined by a third and fourth operator after 1 and 2 years, respectively. MAIN OUTCOME MEASURES Individual operator performance, double perinatal survival at 4 weeks. RESULTS Overall survival of both twins occurred in 59% (201/340), median gestational age at birth was 32.0 weeks. Cumulative sum graphs showed that level of competence for double survival for the operators was reached after 26, 25, 26, and 35 procedures, respectively. Two operators kept their competence level and continued to improve after completing the initial learning process; two others went out of control at one point in time, according to the cumulative sum boundaries. A difference in learning effect was associated with number of procedures performed annually and previous experience with other ultrasound-guided invasive procedures. CONCLUSIONS This study shows that all operators reached a level of competence after at least 25 fetoscopic laser procedures and confirms the value of using the cumulative sum method both for learning curve assessment and for ongoing quality control.
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Affiliation(s)
- Suzanne H P Peeters
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
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Twijnstra A, Hiemstra E, van Zwet E, Balkema E, Dankelman J, Jansen F. Intracorporeal Knot Tying in a Box Trainer: How Proficient Is in Vitro Evaluation in Laparoscopic Experts? J Minim Invasive Gynecol 2014; 21:291-5. [DOI: 10.1016/j.jmig.2013.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 08/09/2013] [Accepted: 09/02/2013] [Indexed: 10/26/2022]
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Cumulative Sum learning curves (CUSUM) in basic anaesthesia procedures☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1097/01819236-201442030-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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22
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Improving the management and outcome in haemolytic disease of the foetus and newborn. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2013; 11:484-6. [PMID: 24120585 DOI: 10.2450/2013.0147-13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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